HEENT 10: Otitis Media Flashcards
What are the common pathogens of otitis media?
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
(all these organisms can have resistance to beta-lactams)
What are the non-modifiable risk factors for otitis media?
- < 5 years
- craniofacial abnormalities
- family history of ear infections
- low birth weight
- male sex
- premature birth
- prior ear infections
- recent viral URTI
- white ethnicity
What are the potentially modifiable risk factors for otitis media?
- exposure to tobacco smoke or environmental air pollution
- factors increasing crowded living conditions (ie. cold seasons, low SES level, daycare/school)
- gastrophageal reflux
- lack of breastfeeding
- pacifier use after age 6 months
- supine bottle feeding
What are the protective factors for otitis media?
- breastfeeding
- routine vaccination – pneumococcal (Prevnar), hemophilus, influenza
What are the symptoms of otitis media?
- ear pain (otalgia)
- fever
- fussiness, irritability
- rubbing or tugging at ear
- difficulty sleeping
- poor feeding
- often follows URTI
How can otitis media be diagnosed?
- gold standard: otoscopic examination of tympanic membrane
- acute presentation with otalgia (< 48 hr)
- middle ear effusion
- inflammation – bulging tympanic membrane or perforated tympanic membrane with otorrhea
Otoscopic Examination of Tympanic Membrane
- 4 signs: colour (red), position (displaced/bulging), translucency (opaque), mobility (immobile tympanic membrane)
- otitis externa if external auditory canal is inflamed, swollen
What are the potential complications of otitis media?
- hearing loss – usually conductive in nature, more common in chronic ear infections
- tympanic membrane perforation
- chronic otitis media
- mastoiditis
- facial paralysis
- intracranial complications – meningitis, brain abscess
What is otitic meningitis?
- signs: fever, neck stiffness, photophobia, and mental status changes
- most commonly seen with S. pneumoniae
When is watchful waiting used?
up to 60% of cases resolve spontaneously in 24 hr
wait up to 48 hr in otherwise healthy children > 6 months if:
- non-severe illness (fever < 39)
- uncomplicated AOM (no recent episode, no mastoiditis, etc.)
- no craniofacial anomalies, immunodeficiencies, down syndrome, cardiac or pulmonary disease, history of complicated AOM
- parents capable of recognizing worsening illness with ready access to car
When is watchful waiting NOT appropriate?
- < 6 months
- perforated tympanic membrane
- ear discharge (otorrhea)
- moderate to severe presentation: severe otalgia with limited response to medications, > 48 hr since symptoms started, temperature > 39
- tympanostomy tubes, cochlear implants
- recurrent AOM
- < 2 with bilateral AOM
- medical comorbidities – ie. immunodeficiency or craniofacial abnormalities
- caregiver unable to support follow-up
What is mild otitis media?
alert, responsive, no rigours, responding to antipyretics, mild otalgia and able to sleep, < 39 fever, < 48 hr of illness
What is moderate or severe otitis media?
irritable, not sleeping, poor response to antipyretics, severe otalgia, fever > 39, symptoms > 48 hr
What is the treatment for AOM in patients ≥ 6 months with severe illness?
antibiotics + analgesic
What is the treatment for AOM in patients ≥ 6 months with non-severe illness or uncertain diagnosis?
watchful waiting for 48 hr + analgesic
What is the treatment for AOM in patients 6 weeks to 6 months?
antibiotics + analgesic
What is the treatment for AOM in patients < 6 weeks?
ER
Pain Control – Oral Analgesics
- acetaminophen 10-15 mg/kg per dose q4-6h (max 75 mg/kg/day or 4000 mg)
- ibuprofen 5-10 mg/kg per dose q6-8h (max 40 mg/kg/day or 2400 mg
- antibiotics alone do not treat ear pain – ear pain may last for 48-72 hr after start of antibiotic
- schedule regularly for first 48 hr
Pain Control – Other Agents
- topical anesthetics (ie. polysporin plus pain relief ear drops) – contraindicated if ear perforation, only last ~30 min
- hot/cold compresses – mixed data on utility
- should be used in addition to oral analgesics
What is the first-line treatment for AOM?
amoxicillin
What are the exceptions to first-line amoxicillin?
- amoxicillin in last 30 days
- history of AOM unresponsive to amoxicillin
- immunocompromised
- allergies
- potentially concurrent purulent conjunctivitis – more likely NOT S. pneumoniae
Standard Dose vs. High Dose Amoxicillin
similar AE – possibly increased risk of rash and diarrhea with HD, but evidence is mixed
When is high dose amoxicillin used?
< 2 years +/- recent antibiotic exposure +/- daycare +/- unimmunized (underimmunized)
Why is high dose amoxicillin used?
related to S. pneumoniae
- develop resistance to penicillin when they express penicillin-binding proteins – makes organism less susceptible to beta-lactam binding
- however when HIGH doses are used → achieve high drug concentrations that can overcome resistance developed through pen-binding proteins
- HOWEVER, there can be beta-lactamase producing organisms that lead to different type of resistance (seen in H. influenzae or M. catarrhalis)
What are the second-line agents for AOM if failure of standard dose amoxicillin?
high dose regimen
What are the second-line agents for AOM if failure of high dose amoxicillin?
SD amox/clav (45 mg/kg/day divided TID x 10 days)
- dose by amoxicillin portion in 7:1 ratio
What are the second-line agents for AOM if failure of amoxicillin/clavulanate?
ceftriazone IM/IV x 3 days
What is considered treatment failure?
no symptomatic improvement after 2-3 days of antibiotics
- middle ear effusion does NOT mean failure – resolve spontaneously by 3 months
What drugs are used if purulent conjunctivitis?
amoxicillin/clavulanate
What drugs are use if non-severe penicillin allergy?
- cefprozil
- cefuroxime
What drugs are use if severe penicillin allergy?
- clarithromycin
- azithromycin
- doxycycline
What is the duration of antibiotic treatment for AOM?
5 days
(or 10 days if < 2 years)
Resistance
- amox/clav covers beta-lactamase + H. influenzae and M. catarrhalis
- high dose amoxicillin covers most PRSP strains
What is recurrent AOM?
≥ 3 episodes in 6 months
How is recurrent AOM treated?
- no antibiotics in last 4-6 weeks: amoxicillin SD or HD x 10 days
- antibiotics in last 4-6 weeks: amox/clav x 10 days
- antibiotic prophylaxis is NOT recommended
- ENT referral may be warranted
What is otitis media with effusion (OME)?
- can have effusion even post-successful treatment or resolution of infection
- usually leave for 3 months – if persists, need to be rechecked
Is there a difference between BID and TID dosing?
no – similar cure rates
- BID easier to manage for parents
Ear Tubes with Ear Drainage
generally do not need to treat
- can use antibiotic drops + corticosteroid (ie. ciprodex (ciprofloxacin and dexamethasone))
- unclear benefit but likely decrease duration of ear drainage
What are tympanostomy tubes?
- allow air into middle ear and prevent fluid from building up behind eardrums
- for children with repeated, long-lasting ear infections
- fall out within 2 yrs
- holes heal on their own
What is the treatment for acute otitis media in adults?
similar to children
- amoxicillin 1 g PO TID x 5 days
- alternative: doxycycline 200 mg PO once, then 100 mg PO BID x 5 days
Is AOM common in adults?
very uncommon
- related to eustachian tube dysfunction, allergic rhinitis, URTI
